Operative management of displaced femoral neck fractures in elderly patients. An international survey

Internal fixation versus total hip arthroplasty for displaced femoral neck fractures in patients aged 60 to 80 years: Patient-reported outcomes and complications

BACKGROUND

The treatment of displaced femoral neck fractures in patients aged 60-80 years old remains controversial. Arthroplasty has been reported to have lower complication rates than internal fixation (IF). However, less is known about the outcomes as perceived by the patient. The aim of the present study (the cross-sectional study) was to evaluate the patient-reported outcome measures (PROMs) of patients aged 60-80 years old with femoral neck fractures treated with IF or total hip arthroplasty (THA).

METHODS

We investigated 92 patients affected by displaced femoral neck fractures who were treated between January 2015 and September 2022. Forty-eight patients were treated with IF, and 44 patients with THA. The outcomes were Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), visual analogue scale (VAS) for pain, and VAS for patient satisfaction at 12 months postoperatively. Complications and reoperations were continuously monitored.

RESULTS

The mean patient age was 68.1 ± 6.6 years. HHS, all dimensions of the HOOS and JHEQ scores, VAS for pain, and VAS for patient satisfaction at 12 months were significantly superior in the THA group compared to the IF group. All outcome measures were superior in the THA group, with mean differences exceeding their respective minimal clinically important differences or minimal detectable changes at 12 months. The rate of major reoperations was significantly higher in the IF group (14.5%) than the THA group (2.2%).

CONCLUSION

We found that patients aged 60-80 years old who underwent THA for displaced femoral neck fractures experienced better outcomes, including PROMs, than those who underwent IF. Furthermore, THA resulted in fewer reoperations than IF.

Does total hip arthroplasty in elderly patients with femoral neck fractures reduce complications? A Japanese DPC study

BACKGROUND

The global increase in femoral neck fractures due to aging and osteoporosis is a major clinical challenge. The debate on the optimal surgical intervention for femoral neck fractures remains unresolved. This large-scale study explores femoral neck fractures among the elderly, focusing on the comparative outcomes of Total Hip Arthroplasty (THA) versus Bipolar Hemiarthroplasty (BHA) in Japanese patients.

METHODS

Using the Japanese National Administrative Diagnosis Procedure Combination (DPC) database, we studied cases of femoral neck fracture from April 2016 to March 2023, and after propensity score matching by age, sex, and comorbidities, we examined the association between THA, complications, and clinical outcomes, and the usefulness of THA for elderly patients with femoral neck fracture.

RESULTS

One-to-one propensity score matching identified 7741 pairs of THA and BHA cases. There was no difference in length of stay between the THA and BHA groups. Significantly more blood transfusions were required in the THA group. There was no significant difference in mortality between the THA and BHA groups, but there was a reduced risk of pneumonia in the THA group, with a ratio of 0.547 (95% CI: 0.418-0.715). On the other hand, the THA group had a higher risk of pulmonary embolism, with a ratio of 1.607 (95% CI: 1.379-1.874). The THA group shows improved discharge rates directly home from the facility where the operation was performed, with a ratio of 1.798 (95% CI: 1.675-1.929).

CONCLUSION

The findings of this research indicate that THA is more effective than BHA in enabling elderly Japanese patients with femoral neck fractures to be discharged directly home and in preventing pneumonia, despite concerns about pulmonary embolism. These findings suggest that THA may improve functional prognosis in elderly patients with femoral neck fractures, although there is a trade-off with an increased risk of pulmonary embolism.

Finite element analysis of the Femoral neck system for different placement positions in the fixation of Pauwels type Ⅲ femoral neck fractures

OBJECTIVE

This study aimed to identify the optimal position for the femoral neck system (FNS) device when fixing Pauwels III #NOF, by analyzing the mechanical stability and stress distribution of FNS at different screw placement positions for the fixation of Pauwels III femoral neck fractures.

METHODS

We employed finite element analysis to create a 3D model of a Pauwels type III femoral neck fracture. Six models were designed, each with varied FNS screw placement positions. Axial stresses of 600 N, 1200 N, and 1800 N were applied to simulate physiological loads during different activities: standing on two legs, standing on one leg, and walking. The mechanical properties of these screw placements were assessed by comparing stress distribution, displacement, and fracture stability across models under varying load conditions.

RESULTS

Model 1, with the power rod aligned along the femoral neck axis, showed the best stability, with 42.40 % lower maximum VMS and 18.49 % less femoral displacement, compared to the worst model. Displacement of the internal fixation and fracture surface decreased by 21.72 % and 19.16 %, respectively. It also had superior results for internal fixation VMS and fracture surface compressive stress. Model 2, with the head screw centered axially, demonstrated good stability but had higher stress concentrations under 1800 N load. The displacement of the fracture surface and femur in model 2 increased by 18.37 % and 17.26 %, respectively, compared to model 1. Models 5 and 6, with the FNS nail near the lateral femoral cortex, showed significant stress concentrations, with compressive and shear forces rising by about 33 %. Model 5's maximum VMS increased by 46.68 %, and model 6's maximum compressive stress of the fracture surface increased by 46.37 %, compared to model 1. Models 3 and 4, with the power rod shifted up or down, displayed moderate stability, reducing displacement in some tests.

CONCLUSION

This finite element analysis highlights that centring the FNS power rod along the femoral neck axis significantly enhances fracture stability and minimises postoperative displacement. Conversely, poor screw placement may result in mechanical stress concentration, raising the risk of nonunion or malunion. Clinicians should prioritise screw placements with more excellent mechanical stability to optimise treatment outcomes.

Outcomes of Staphylococcal Prosthetic Joint Infection After Hip Hemiarthroplasty: Single Center Retrospective Study

Background and Objectives: When prosthetic joint infections, known for their high morbidity, are caused by high-virulence organisms such as Staphylococcus, the outcomes are even worse. This study aims to examine the outcomes of staphylococcal prosthetic joint infections after hemiarthroplasty for hip trauma patients, which has not been particularly reported. Materials and Methods: A retrospective study was performed in a level 1 trauma center to review all the cases of prosthetic joint infections in our database. Patients' demographics, clinical inpatient, surgical, and outpatient notes, laboratory results, and serial radiographs were assessed to extract all relevant data. Results: Out of 2477 hip hemiarthroplasty cases reviewed, a total of 36 prosthetic joint infection cases caused by Staphylococcus species in 36 patients were included in this study. Patients were 26 females and 10 males with a mean age of 76.5 years at the time of surgery. Fifteen cases had infections with methicillin-resistant Staphylococcus aureus (MRSA) while twenty-one cases had infections with other Staphylococcus species. The mean follow-up for all cases is 43.5 months. Twenty-nine cases underwent at least a single trial for surgical debridement and implant retention surgery, and only nine (31%) had successful debridement and implant retention. The 3-month, 1-year, and 3-year cumulative mortality for all cases was 22.2, 30.5, and 41.7%, respectively. Conclusions: Staphylococcal hemiarthroplasty infection is a devastating complication that is associated with a low success (31%) of implant retention surgery, significantly high morbidity, and high cumulative mortality.

Impact of Intraoperative Femoral Fractures During Cemented Hemiarthroplasty for Femoral Neck Fractures

BACKGROUND

There have been several studies on intraoperative femoral fractures (IFFs) during primary total hip arthroplasty, but it is not well understood how this complication affects the patient population undergoing cemented hemiarthroplasty. This study aimed to analyze the impact of IFFs sustained during cemented hemiarthroplasty for the treatment of femoral neck fractures.

METHODS

A retrospective review was conducted of all patients who were treated for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association 31B fractures with cemented hemiarthroplasty between January 1, 2000 and December 31, 2021, at a single academic level 1 trauma center. An initial cohort was constructed of all patients who sustained an IFF during their surgery, yielding 31 patients after excluding those who sustained a pathologic fracture or had incomplete data. These patients were matched 1:2 on age, sex, and body mass index to patients in a control cohort. The primary outcome measure was implant failure. Secondary outcome measures included complications, all-cause mortality, and radiographic outcomes (subsidence, femoral component loosening, acetabular wear, and heterotopic ossification) postoperatively.

RESULTS

Subsequent implant revision was required in 3.2% (n = 1) of patients who sustained an IFF and 1.6% (n = 1) of patients who did not. After adjusting for comorbidities, there was no observed excess risk of implant failure in the fracture cohort when compared to the control cohort (hazard ratio [HR] = 0.30, P = 0.740). There was no observed excess risk of morbidity (HR = 0.69, P = 0.621) or all-cause mortality (HR = 0.23, P = 0.330). Radiographic outcomes also did not significantly differ between the 2 cohorts (P > 0.05).

CONCLUSIONS

Intraoperative fractures during cemented hemiarthroplasty do not contribute to an increased risk of secondary surgery, morbidity, or mortality after surgery. They also do not adversely affect radiographic outcomes postoperatively.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Mortality and functional outcomes in elderly adults treated surgically by hemiarthroplasty for femoral neck fractures

Background

Despite multiple studies, less recent literature and data regarding the mortality associated with hip fractures in the elderly population are available.

Objectives

To assess the mortality data and functional outcomes of patients who underwent cemented and uncemented hemiarthroplasty in femoral neck fractures. To evaluate if preoperative (minimum 2 months) calcium and vitamin D supplement intake in patients affects postoperative mobilization with or without walker support.

Methods

All patients aged 65 and above who underwent hemiarthroplasty for femoral neck fractures in our tertiary care center were included. Postoperative functional outcomes were determined using the Modified Harris Hip score and Oxford Hip score at 3, 6, and 12 months. The mortality of the procedures was assessed at 3, 6, and 12 months. Individuals who took both calcium and vitamin D supplements for at least 2 months before surgery were divided into two groups: those who did not take supplements and those who did.

Results

We studied 110 patients above the age of 65 years. The postoperative mortality rate at 3, 6 months and 1 year postoperatively was found to be 3.6%, 4.7%, and 15.5% respectively. Functional outcomes were assessed at 3, 6, and 12 months postoperatively using modified Harris Hip score and Oxford Hip score and were found to be identical in both cemented and uncemented hemiarthroplasty groups. Patients who took calcium and vitamin D supplements preoperatively (minimum 2 months) could walk without support at the end of 1-year post-surgery.

Conclusion

Early surgery and early mobilization should be the main aim of treatment for femoral neck fractures.

Biomechanical comparison of Gofried positive support reduction of Pauwels type III femoral neck fractures: A finite elements analysis

OBJECTIVE

This study aims to investigate the biomechanical characteristics of non-anatomical reduction and different screw positions on the stability of Pauwels type III femoral neck fractures.

METHODS

Three-dimensional finite element models of femoral neck fractures were constructed using CT images. Four types of internal fixation methods were simulated, including biplane double-supported screw fixation (BDSF), three inverted triangular parallel cannulated screws (3CS), new parallel cannulated screws with posterior screws moving down (New 3CS), and two parallel cannulated screws (2CS). von Mises stress and total displacement were compared between the fracture models after the femoral head was subjected to an axial load of 2100 N. Stress and displacement data for the implants and the femur were recorded for each fixation method and compared.

RESULTS

The results demonstrated that positive reduction of a Pauwels type III femoral neck fracture provided greater stability than neutral or negative reduction. Specifically, the BDSF group showed the lowest maximum von Mises stress in the femur (17.66 MPa) in positive reduction, compared to 3CS (21.08 MPa), New 3CS (22.14 MPa), and 2CS (36.57 MPa). The total displacement of positive reduction in the BDSF group was 0.3143 mm, which was lower than in the 3CS (0.3498 mm), New 3CS (0.3343 mm), and 2CS (0.4533 mm) groups. The stress distribution in the positive support reduction group was lower than that of the other groups, indicating better load distribution. Among the three-screw fixation methods, the New 3CS system exhibited the highest stress in the screws (with a peak of 28.62 MPa), while the 2CS group displayed the highest stresses overall, both in the femur and the screws.

CONCLUSION

For Pauwels type III femoral neck fractures, a positive support reduction with BDSF fixation exhibited superior biomechanical performance than negative reduction. Based on the finite element analysis conducted in this study, the positive support reduction with BDSF fixation can enhance fixation stability, suggesting that non-anatomical reduction is recommended.

Outcomes of internal fixation with Femoral Neck System (FNS) for intracapsular femoral neck fractures

Background

Internal fixation of hip fractures is associated with high reoperation rates. This study investigated the reoperation rates after internal fixation with the femoral neck system (FNS).

Materials and Methods

A single-institution cohort study was conducted on patients aged 18 years or older who sustained intracapsular femoral neck fractures and underwent internal fixation with a fixed-angle implant. Surgeons, patients, and investigators were not blinded. The primary outcome was any hip reoperation at the final follow-up. Secondary outcomes were to characterize a cohort of patients regarding demographics, fracture classification, intraoperative findings, postoperative fracture complications and union rates, and postoperative pain.

Results

This study found that internal fixation with FNS for intracapsular femoral neck fractures was associated with a 23% rate of revision surgery. Of the initial 94 patients who received FNS internal fixation, 44 patients were included for analysis; of those, 10 patients underwent revision surgery. Patients had a 22% rate of in-hospital medical adverse events with a 30-day readmission rate of 9%. Increasing body mass index was associated with increased revision rates (P = 0.037). Patients who sustained displaced femoral neck fractures had a significant decrease in SF-12 Mental Health Composite, SF-12 Physical Health Composite, and quality-of-life subscale scores.

Conclusions

The FNS is a viable alternative for internal fixation of intracapsular femoral neck fractures. The observed rate of revision after internal fixation was comparable with previously published outcomes following fixation with cannulated screws and sliding hip screws.

Level of Evidence

Level IV, Therapeutic Study.

Comparing surgical readmission, in-hospital complications, and charges between total hip arthroplasty and hemiarthroplasty for geriatric femoral neck fractures

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

Methods

The Hospital Quality Monitoring System was queried from 1 January 2013 to 31 December 2019 for displaced FNFs in geriatric patients treated with THA or HA. After propensity score matching, which identified 33,849 paired patients, outcomes were compared between THA and HA using logistic and linear regression models.

Results

The HA group had a lower incidence of 90-day surgical readmission than the THA group (odds ratio (OR) 0.75 (95% CI 0.68 to 0.83)). Meanwhile, the HA group had lower incidence of dislocation (OR 0.42 (95% CI 0.33 to 0.52)), aseptic loosening (OR 0.50 (95% CI 0.38 to 0.66)), and joint pain (OR 0.63 (95% CI 0.40 to 0.98)), but a higher incidence of periprosthetic fracture (OR 1.41 (95% CI 1.07 to 1.87)) for readmission, compared to the THA group. The incidence of in-hospital complications did not differ significantly between the two groups. Moreover, the HA group had lower mean charges than the THA group (47,578.29 Chinese Yuan (CNY) (SD 20,069.71) vs 57,641.00 CNY (SD 21,524.07)).

Conclusion

When considering 90-day surgical readmission rate, in-hospital complications, and mortality, HA resulted in a significantly lower surgical readmission rate within 90 days compared to THA, despite the patients being older and having a higher Charlson Comorbidity Index.

Symptomatic Acetabular Erosion After Hip Hemiarthroplasty: Is It a Major Concern? A Retrospective Analysis of 2477 Hemiarthroplasty Cases

Background/Objectives: Acetabular erosion is a postoperative condition that can occur after hip hemiarthroplasty (HA), potentially leading to pain and requiring conversion to total hip arthroplasty (THA). Given the discrepancy in its incidence and impact in the literature, this study aims to report the incidence of symptomatic acetabular erosion and the subsequent conversion to THA in all HA cases performed in a single health system. Methods: A total of 2477 HA cases had their clinical notes and serial radiographs examined for this retrospective study. Outcome measures included any records of hip or groin pain and conversion to THA that were attributed to acetabular erosion as documented in the clinical notes. Results: Two thousand four hundred and seventy-seven HA cases were reviewed in this study. The mean age for all patients in the study was 81.5 years and the mean follow up was 3.7 years. Out of the 2477 HA cases, only 12 HA cases (0.48%) in 12 patients had data records of chronic hip pain, attributable to acetabular wear in the clinical notes, of variable severity and presentations. The mean duration until the clinical documentation of acetabular wear-induced pain was 25.6 months (range, 1.4-146.4 months), with most symptomatic hip erosion cases presented within the first year (50% presented within the first 6 months) after the index HA surgery. Despite that, only five cases underwent conversion to THA (0.2%) while seven patients received conservative management. Conclusions: In patients older than 65 years of age who are candidates for HA, the incidence of symptomatic hip erosion and the subsequent conversion to THA is low and hence HA remains a viable treatment option. Based on the duration until clinical presentation of acetabular erosion, this study suggests that the state of acetabular cartilage during surgery may influence the development of early acetabular wear in most symptomatic patients. On the other hand, hip hemiarthroplasty is a rare treatment option for displaced femoral neck fractures in patients younger than 65 years of age, and its use in this patient subset depends on conditional and patient-related factors such as the activity level, cognitive function, and medical comorbidities.

Effects of Cerclage Cabling on Preventing Periprosthetic Femoral Fractures When Using Cementless Stems for Unstable Femoral Neck Fractures

BACKGROUND

Periprosthetic femoral fractures (PFFs) are serious complications in hip arthroplasty for femoral neck fractures. The rates of intraoperative (iPFFs) and postoperative PFFs (pPFFs) are higher in cementless stem cases than in cemented cases. This study aimed to investigate the effects of cerclage cabling on PFF prevention in cementless arthroplasty for femoral neck fractures.

METHODS

This retrospective study included 329 consecutive patients who underwent hip arthroplasty using a cementless stem for femoral neck fractures. A total of 159 and 170 patients were in the non-cabling and cabling groups, respectively. Patient characteristics were comparable in both groups. The PFF occurrence (iPFF and pPFF) rates, reoperation rates, operative time, and blood loss volume were compared between the groups.

RESULTS

The iPFF rate was significantly higher in the noncabling group (6.3%) than in the cabling group (0%, P < .001). The rate of pPFF was significantly higher in the non-cabling group (5.1%) than in the cabling group (0.6%; P = .016). All patients in the non-cabling group required reoperation (5.1%), whereas the patient in the cabling group was an ambulatory case and required no reoperation (0%, P = .003). No significant difference in either operative time or blood loss volume was observed between the non-cabling (50 minutes, 133 mL) and cabling (52 minutes, P = .244; 149 mL, P = .212, respectively) groups.

CONCLUSIONS

When a cementless stem is used to treat unstable femoral neck fractures, cerclage cabling effectively prevents iPPF and pPPF without increasing surgical time or blood loss volume.

Dual mobility cup in hip fracture: Indications and clinical results compared with bipolar hip arthroplasty

INTRODUCTION

The choice between hemiarthroplasty (HA) and total hip arthroplasty (THA) for displaced femoral neck fractures remains debated. There is increasing use in dual mobility cup total hip arthroplasty (DMC-THA) to prevent dislocations in these high-risk patients. Aim of this study is to retrospectively analyze patients treated in a single Center for femoral neck fracture comparing HA and DMC-THA in terms of: functional outcome, rate of complications and mortality.

MATERIAL AND METHODS

Between 2020 and 2022, 162 patients were included, 39 male and 123 female, with a mean age of 76 years old. HA were implanted in 82 cases and DMC-THA in 80 cases. INCLUSION CRITERIA WERE: age < 85 years old, American Society of Anesthesiologists (ASA) score below 3, minimum follow-up of 6 months. Overall, 124/162 of patients (77%) were surgically treated within 48 h from admission.

RESULTS

The mean age for DMC-THA group was 74 years old and 78 years old for HA group. The overall mean surgical time was significantly higher in the DMC-THA group (P < 0.001). Mean hemoglobin (Hb) loss was 1.64 g/dl in the HA group and 1.72 g/dl in the DMC-THA group with no differences between the two groups (P = 0.573). There is no difference in survival of patients between the two groups (P = 0.7704). In the HA group, the mean one-month post-operative VAS score was 2.1, while in the DMC-THA group was 0.9. The Harris hip score was significantly better in DMC-THA group (P = 0.035) Dislocation never occured in the overall series. Infection occurred only in one patient with DMC-THA and was treated with debridement. Periprosthetic fracture occurred in 2 cases of DMC-THA both within 1 month from the first surgery; one was treated with revision femoral stem and the second one with fixation.

CONCLUSIONS

DMC-THA offer better functional results than HA in elderly patients with femur neck fractures. The mean surgical time was longer in DMC-THA but this did not influence blood loss, time of discharge or one-year mortality. In our series dislocation never occurred in both groups.

Perioperative geriatrics: A bibliometric analysis of the top 100 cited articles in an emerging specialty

BACKGROUND

The success of modern medicine has led to surgery being performed on an increasingly older, frailer and more comorbid population. As a result, perioperative geriatrics has emerged as an important specialty, relevant to both medical and surgical disciplines. Only a small number of papers have been published on the topic. A bibliometric analysis is used to identify themes and trends in current research and practice.

OBJECTIVES

To identify and describe research topics relating to perioperative geriatrics; to find themes and gaps in the current literature.

METHODS

Thompson Reuters Web of Science indexing database was searched for all manuscripts relating to perioperative geriatrics. Of these, the top 100 were subcategorised into manuscript type, age, theme, specialty, journal and citation rate.

RESULTS

The highest cited article was by Bhandari et al with 294 citations. The highest citation rate was achieved by Partridge et al, with 23.75 citations/year. Across the series, the mean number of citations was 50.41 (range 294-12). The highest number of manuscripts were published between 2010 and 2019 (n = 55), with 70% of manuscripts published in journals with impact factor <5. The specialty with the highest number of publications was orthopaedics (n = 36). Most articles focussed on surgical management of geriatrics patients, followed by anaesthetic management.

CONCLUSION

This is the first bibliometric analysis of the top 100 most cited papers in perioperative geriatrics. Only 395 papers were returned, indicating that this needs to be further researched as a topic. Key themes identified were surgical management of hip fractures and anaesthetic preoperative assessment. Emerging themes from this study highlight the need for perioperative publications in the fields of geriatric vascular, general, plastic and gynaecology.

Factors that influence surgical decision-making for geriatric displaced femoral neck fractures: Bullet Health Analysis (BHA) I : Worldwide Orthopaedic Research Collaboration: Leveraging Big Data (WORLD) I

PURPOSE

The management of geriatric femoral neck fractures, which includes options like hemiarthroplasty (HA), total hip arthroplasty (THA), and fixation, exhibits regional and healthcare setting variations. However, there is a lack of information on global variations in practice patterns and surgical decision factors for this injury.

METHODS

Survey data were collected from April 2020 to June 2023 via Orthobullets Case Studies, a global clinical case collaboration platform hosted on a prominent orthopedic educational website. Collaboratively developed standardized polls, based on the best available evidence and a comprehensive, peer-reviewed, evidence-based item list, were used to capture surgeons' treatment preferences worldwide. Subsequent analyses explored preferences within subspecialties and practice settings. Multivariable regression analysis identified associations between subspecialty, practice type, the likelihood of choosing THA, and the preferred femoral fixation method.

RESULTS

Our study encompassed 2595 respondents from 76 countries. Notably, 51.5% of participants (n = 1328; 51.5%, 95% CI 49.6-53.4%) leaned towards THA and 44.9% for HA, while 3.6% favoured surgical fixation. Respondents affiliated with academic institutions and large non-university-affiliated hospitals were 1.74 times more likely to favour THA, and arthroplasty specialists exhibited a 1.77-fold preference for THA. There was a 19-fold variation for cemented femoral fixation between the United Kingdom (UK) and USA with the UK favouring cemented fixation.

CONCLUSION

Our study reveals a significant shift towards THA preference for managing geriatric femoral neck fractures, influenced by subspecialty and practice settings. We also observed a pronounced predominance of cement fixation in specific geographic locations. These findings highlight the evolving fracture management landscape, emphasizing the need for standardization and comprehensive understanding across diverse healthcare settings.

Higher rates of intraoperative fractures with compaction broaching compared to conventional broaching during hip hemiarthroplasty for femoral neck fractures

PURPOSE

Intraoperative periprosthetic femoral fracture (IPFF) is a known iatrogenic complication during hemiarthroplasty (HA) which may lead to inferior outcomes. The risk factors for IPFF during HA in displaced femoral neck fractures (FNF) remains to be fully elucidated. This study aims to compare IPFF rates between compaction broaching and conventional broaching techniques for cementless HA in FNF.

METHODS

We retrospectively reviewed institutional surgical data of patients who underwent cementless HA for displaced FNF from January 2010 to January 2022. Patients were stratified into two groups based on the broaching system: conventional broaching and compaction broaching. The presence, location, and treatment of IPFF were assessed for both groups. Effect of IPFF on postoperative weight-bearing status, mortality readmission and revision rates were compared between groups.

RESULTS

A total of 1,586 patients included in the study. 1252 patients (78.9%) in the conventional broaching group and 334 patients (21.1%) in the compaction broaching group. A total of 104 IPFF were found (6.5%). As compared to conventional broaching, compaction broaching was associated with significant higher IPFF rates (12.9% vs. 4.9%, p < 0.001, OR 2.84, CI 1.88-4.30). The location of the IPFF was similar between groups (p = 0.366), as well as the intraoperative treatment (p = 0.103) and postoperative weight-bearing status (p = 0.640). Surgical time, mortality rates, readmission rates and revision rates were comparable between groups. In a multivariate regression analysis, compaction broaching (OR, 4.24; p < 0.001) was independently associated with IPFF.

CONCLUSIONS

This study reveals higher rates of IPFF associated with compaction broaching. Although this finding may have minimal clinical relevance, surgeons should consider these results when considering implant selection.

Revision rate following unipolar versus bipolar hemiarthroplasty

INTRODUCTION

There has been much debate on use of bipolar or unipolar femoral heads in hemiarthroplasty for the treatment of femoral neck fractures. The outcome of these implants should be studied in the America Joint Replacement Registry (AJRR).

METHODS

All primary femoral neck fractures treated with hemiarthroplasty between January 2012 and June 2020 were searched in the AJRR. All cause-revision of unipolar and bipolar hemiarthroplasty and reasons for revision were assessed for these patients until June of 2023.

RESULTS

There were no differences in number and reason for all cause revisions between unipolar and bipolar hemiarthroplasty (p = 0.41). Bipolar hemiarthroplasty had more revisons at 6 months postoperatively (p = 0.0281), but unipolar hemiarthroplasty had more revisions between 2 and 3 years (p = 0.0003), and after 3-years (p = 0.0085), as analysed with a Cox model. Patients with older age (HR = 0.999; 95% CI, 0.998-0.999; p = 0.0006) and higher Charlson Comorbidity Index (HR = 0.996; 95% CI, 0.992- 0.999; p = 0.0192) had a significant increase in revision risk.

CONCLUSIONS

We suggest that surgeons should consider using bipolar prosthesis when performing hemiarthroplasty for femoral neck fracture in patients expected to live >2 years post injury.

Age-Based Heuristics Bias Treatment of Displaced Femoral Neck Fractures in the Elderly

Background

Surgeons performing arthroplasty for femoral neck fractures may rely on mental shortcuts (heuristics) when choosing total hip arthroplasty (THA) vs hemiarthroplasty (HA). We sought to quantify the extent to which age-based heuristics drive decision-making.

Methods

We identified all Medicare beneficiaries from 2017-2018 with femoral neck fractures who underwent THA or HA. We compared the likelihood of THA vs HA among patients admitted within 4 weeks before vs 4 weeks after their birthday for each age under the hypothesis that these cohorts would be similar except for numerical age. We controlled for race/ethnicity, sex, comorbidities, poverty status, and hospital census region in a multivariable regression that included facility-level cluster effects. We generated predicted/adjusted probabilities for THA vs HA for different age transition points.

Results

Thirteen thousand three hundred sixty-six elderly patients were included. One thousand eight hundred sixty-five (14%) received THA and 11,501 (86%) received HA. The likelihood of THA decreased from 50.3% among patients almost 67 to 8% among those ≥85 (P < .001). We found significant decreases in likelihood of THA across age transitions. The largest decrement was at age transition 69 (THA likelihood 28.7% for newly 69 vs 43.3% for almost 69, 33.7% relative change). Female gender, Black race, higher comorbidity burden, and lower socioeconomic status were also associated with a lower likelihood of THA.

Conclusions

Our data demonstrate that patient age transitions seem to influence the choice of THA vs HA. Further research is needed to develop data-driven surgical decision aids for this population.

Posterior Approach and Inferior Capsulotomy in Bipolar Hemiarthroplasty for Femoral Neck Fractures: Comparison with Superior Capsulotomy

Background

Hemiarthroplasty is frequently used to treat displaced femoral neck fractures in elderly patients, but it has a higher risk of postoperative dislocation. We introduced the posterior approach and inferior capsulotomy (PAICO) to enhance joint stability after bipolar hemiarthroplasty for femoral neck fracture. We evaluated whether the PAICO would have a lower dislocation rate than the conventional posterior approach with superior capsulotomy.

Methods

From January 2021 to December 2021, we prospectively recruited 25 patients (25 hips) aged 50 years or older who underwent bipolar hemiarthroplasty for femoral neck fractures due to low-energy trauma as the PAICO group. We compared the PAICO group with a historical control group who had undergone hemiarthroplasty in 7 institutes between 2010 and 2020. The primary endpoint was dislocation within 1 year after the surgery. We compared data from the PAICO group with the data from the historical control group from the Korean Hip Fracture Registry which was carried out in South Korea.

Results

A total of 25 patients (25 hips) were enrolled in the present study; 3,477 patients (3,571 hips) who underwent bipolar hemiarthroplasty were reviewed as the historical control group. In the PAICO group, we observed no dislocation, whereas the dislocation rate in the control group was 1.3%.

Conclusions

In patients with displaced femoral neck fractures, the PAICO approach demonstrated comparable results in operation time and complication rates when compared to bipolar hemiarthroplasty using superior capsulotomy. Notably, there were no observed cases of dislocation among patients who underwent the PAICO approach. We recommend this PAICO approach to surgeons using the posterior approach, hoping to prevent dislocation in bipolar hemiarthroplasty.

Early Postoperative Weight-Bearing Ability after Total Hip Arthroplasty versus Bipolar Hemiarthroplasty in Elderly Patients with Femoral Neck Fracture

Background: Femoral neck fractures are among the most common types of fractures and particularly affect elderly patients. Two of the most common treatment strategies are total hip arthroplasty (THA) and bipolar hemiarthroplasty (BA). However, the role of the different treatment strategies in the postoperative weight-bearing ability in the early postoperative phase is still not entirely clear. Methods: Patients who underwent either THA or BA were consecutively included in our prospective cohort study. Gait analysis was performed during the early postoperative period. The gait analysis consisted of a walking distance of 40 m coupled with the turning movement in between. During the gait analysis, the duration of the measurement, the maximum peak force and the average peak force were recorded. Results: A total of 39 patients were included, 25 of whom underwent BA and 14 of whom underwent THA. The maximum peak force during the gait analysis was, on average, 80.6% ± 19.5 of the body weight in the BA group and 78.9% ± 21.6 in the THA group. The additionally determined average peak force during the entire gait analysis was 66.8% ± 15.8 of the body weight in the BA group and 60.5% ± 15.6 in the THA group. Conclusions: Patients with femoral neck fractures undergoing THA and BA can achieve sufficient weight bearing on the operated leg in the early postoperative period. In our study, BA did not allow for a significantly higher average and maximum loading capacity compared with THA.

Predictors of long-term mortality in older patients with hip fractures managed by hemiarthroplasty: a 10-year study based on a population registry in Saxony, Germany

BACKGROUND

Mortality of patients with a femoral neck fracture is high, especially within the first year after surgery, but also remains elevated thereafter. The aim of this study was to identify factors potentially associated with long-term mortality in patients homogeneously treated with hemiarthroplasty for femoral neck fracture.

METHODS

This retrospective cohort study was performed at a single level 1 national trauma center at the university hospital of Leipzig (Saxony, Germany). The study time-window was January 1, 2010 to December 31, 2020. Primary outcome measure was mortality depending on individual patient-related characteristics and perioperative risk factors. Inclusion criteria was a low-energy femoral neck fracture (Garden I-IV) in geriatric patients 60 years of age or older that were primarily treated with bipolar hemiarthroplasty. Date of death or actual residence of patients alive was obtained from the population register of the eastern German state of Saxony, Germany. The outcome was tested using the log-rank test and plotted using Kaplan-Meier curves. Unadjusted and adjusted for other risk factors such as sex and age, hazard ratios were calculated using Cox proportional hazards models and presented with 95% confidence intervals (CI).

RESULTS

The 458 included patients had a median age of 83 (IQR 77-89) years, 346 (75%) were female and 113 (25%) male patients. Mortality rates after 30 days, 1, 5 and 10 years were 13%, 25%, 60% and 80%, respectively. Multivariate regression analysis revealed age (HR = 1.1; p < 0.001), male gender (HR = 1.6; p < 0.001), ASA-Score 3-4 vs. 1-2 (HR = 1.3; p < 0.001), dementia (HR = 1.9; p < 0.001) and a history of malignancy (HR = 1.6; p = 0.002) as independent predictors for a higher long-term mortality risk. Perioperative factors such as preoperative waiting time, early surgical complications, or experience of the surgeon were not associated with a higher overall mortality.

CONCLUSIONS

In the present study based on data from the population registry from Saxony, Germany the 10-year mortality of older patients above 60 years of age managed with hemiarthroplasty for femoral neck fracture was 80%. Independent risk factors for increased long-term mortality were higher patient age, male gender, severe comorbidity, a history of cancer and in particular dementia. Perioperative factors did not affect long-term mortality.

Comparison of the Surgical Outcome between the Multiple Screw Fixation and Fixed Angle Devices for the Basicervical Femoral Neck Fractures

Introduction: Basicervical femoral neck fracture (FNF) is an uncommon type of femoral neck fracture and is associated with an increased risk of fixation failure due to its inherent instability. The purpose of this study was to compare the surgical parameters and reoperation rate between the use of a multiple cannulated screw (MCS) and fixed angle device (FAD) in treating basicervical FNFs. Methods: We retrospectively reviewed the records of 885 patients who underwent internal fixation between May 2004 and August 2019 to determine basicervical FNF with at least 12 months of follow-up. Among the identified 77 patients with basicervical FNF, 17 patients who underwent multiple cannulated screw (MCS) fixation and 36 patients who underwent fixed angle device (FAD) fixation were included. We compared the rates of fracture-site collapse and reoperations according to the fixation device. Results: Among the 53 patients with basicervical FNF, 13 patients (24.5%) sustained surgical complications (8 collapses of fracture site and 5 reoperations). The reoperation rate in the MCS group was significantly higher than that in the FAD group (23.5% vs. 2.8%, p = 0.016), without any significant difference in the collapse of the fracture site (11.8% vs. 16.7%, p = 0.642). Conclusions: Although basicervical FNF was rare among hip fractures, fracture site collapse was prevalent and prone to fixation failure. Surgeons should keep this in mind, and consider FAD for basicervical FNF.

Single-plane osteotomy model is inaccurate for evaluating the optimal strategy in treating vertical femoral neck fractures: A finite element analysis

BACKGROUND AND OBJECTIVES

The conventional method for simulating vertical femoral neck fractures (vFNFs) is via a vertical single-plane osteotomy (SPO) across the entire femur. However, the accuracy of SPO for evaluating the optimal internal fixation strategy (IFS) and the appropriate assessment parameters is not clear. This study thus aimed to examine the accuracy of SPO in evaluating IFSs and to identify appropriate evaluation parameters using finite element analysis.

METHODS

Eighty patient-specific finite element models were developed based on CT images from eight vFNF patients. The natural fracture model was built using structural features of the affected side, while the SPO was simulated on the healthy side. Five different IFSs were applied to both the natural fracture and SPO groups. Thirteen parameters, including stress, displacement, and stiffness, were subjected to a two-way repeated measures ANOVA to determine the effect of IFSs and fracture morphology on stability. A Pearson correlation analysis was performed on varied parameters with various IFSs to identify independent parameters. Based on these independent parameters, the entropy evaluation method (EEM) score was used to rank the performance of IFSs for each patient.

RESULTS

Eight of the thirteen parameters were significantly influenced by IFSs (p < 0.05), two by fracture morphology (p < 0.01), and none by the interaction between IFS and fracture morphology. In the natural fracture group, parameters including screw stress and displacement, bone cut rate (BCR), and compression effects varied independently with distinct IFSs. In the SPO group, trunk displacement, BCR, cut-out risk, and compression effects parameters changed independently. The BCR of the Alpha strategy was significantly higher than that of the Inverted strategy in the natural fracture group (p = 0.002), whereas the opposite was observed in the SPO group (p = 0.016). Regarding compression effects, two IFS pairings in the natural fracture group and seven IFS pairings in the SPO group exhibited significant differences. None of the five IFSs achieved the optimal EEM score for each patient.

CONCLUSIONS

The single-plane osteotomy model may have limitations in assessing IFSs, particularly when the bone cut rate and compression effects are the main influencing factors. Parameters of the screw stress and displacement, BCR, and compression effects appear to be relevant in evaluating IFSs for natural fracture models. It indicates that individualized natural fracture models could provide more comprehensive insights for determining the optimal IFS in treating vFNFs.

Age as a Risk Factor for Intraoperative Periprosthetic Femoral Fractures in Cementless Hip Hemiarthroplasty for Femoral Neck Fractures: A Retrospective Analysis

Background

Understanding the risk factors and outcomes of intraoperative periprosthetic femoral fractures (IPFF) during hip arthroplasty is crucial for appropriate perioperative management. Previous studies have identified risk factors for IPFF in total hip arthroplasty patients, but data for hip hemiarthroplasty (HA) is lacking. The aim of this study was to determine the age associated with increased rates of IPFF in patients undergoing HA.

Methods

We retrospectively reviewed patients aged 65 years and above who underwent a cementless HA for a displaced femoral neck fracture and had a minimum of 1-year follow-up. Patients were stratified into five age groups (65-79, 80-84, 85-89, 90-94, and ≥ 95 years) and further divided into two subgroups (under 95 years and 95 years or older). The presence, location, and treatment of IPFF, as well as the effect of IPFF on the postoperative weight-bearing status, were compared between groups. A multivariate logistic regression was also performed. A total of 1,669 met the inclusion criteria and were included in the study.

Results

The rates of IPFF were significantly higher for patients 95 years or older (p = 0.030). However, fracture location (greater trochanter fractures, p = 0.839; calcar fractures, p = 0.394; and femoral shaft fractures p = 0.110), intraoperative treatment (p = 0.424), and postoperative weight-bearing status (p = 0.229) were similar between the groups. While mortality and nonorthopedic-related readmissions were significantly higher for patients 95 years or older, orthopedic-related readmissions (p = 0.148) and revisions at the latest follow-up (p = 0.253) were comparable between groups. In a regression analysis, age over 95 years (odds ratio, 2.049; p = 0.049) and body mass index (odds ratio, 0.935; p = 0.016) were independently associated with IPFF.

Conclusions

The findings of this study suggest that age over 95 years is a significant, independent risk factor for IPFF in patients undergoing cementless HA. Although we were unable to show an impact on perioperative outcomes and orthopedic complications, when operating on patients 95 years or older, surgeons should be aware of the increased risk of IPFF and consider the use of stem designs and fixation types associated with decreased IPFF rates.

Health economics for intra-capsular hip fractures undertaking fixation

BACKGROUND

Hip fracture is a common musculoskeletal injury in the elderly requiring surgery worldwide. The operative mainstay of intra-capsular hip fractures is arthroplasty with a smaller proportion for fixation.

AIM

To determine the most beneficial method of fixation for patients with intra-capsular hip fractures.

METHODS

A registered audit from 2012-2018 was conducted on all intra-capsular hip fractures treated with 2 commonly used fixation methods. Patient notes, electronic records and clinical codes for cost benefit were evaluated. A validated quality of life measure was collected at least 1 year after surgery.

RESULTS

A total of 83 patients were identified with intra-capsular fractures undergoing fixation during the retrospective period. There were 47 cannulated cancellous screw and 36 sliding hip screw fixations with the case mix comparable for age, gender, co-morbidities and fracture configuration. There was no significant difference in blood loss, tip apex distance, radiation exposure, length of stay, radiological union time, collapse, avascular necrosis or re-operation between fixation methods. Logistic regression analysis demonstrated displaced intracapsular hip fractures correlated significantly with an undesirable outcome conferring a relative odds ratio of 7.25. There were 9 (19%) and 4 (11%) patients respectively, who required re-operation. There was no significant difference in health resource group tariff and implant cost with comparable EQ-5D and visual analogue scores.

CONCLUSION

No significant advantage was identified with differing fixation type, but irrespective there were a high number of patients requiring re-operation. This was predicted by initial fracture displacement and patient age. Arthroplasty may need to be carefully considered for health economics and patient benefit.

Femoral neck system versus multiple cannulated screws for the fixation of Pauwels classification type II femoral neck fractures in older female patients with low bone mass

BACKGROUND

Femoral neck fractures in older adult patients are a major concern and often necessitate surgical intervention. This study compared the clinical outcomes of 2 surgical techniques: the femoral neck system (FNS) and cannulated compression screws (CCSs).

METHODS

A total of 40 female patients (mean age 73.50 ± 11.55 years) with femoral neck fractures of Pauwels classification type II and receiving surgical fixation between 2020 and 2022 were enrolled. The patients were categorized into an FNS group (n = 12) or a CCS group (n = 28), and surgical duration, intraoperative blood loss, length of hospital stay, and incidence of postoperative adverse events were analyzed.

RESULTS

No significant intergroup differences in demographic characteristics were discovered. The mean surgical duration for all patients was 52.88 ± 22.19 min, with no significant difference between the groups. However, the FNS group experienced significantly higher intraoperative blood loss (P = 0.002) and longer hospital stay (P = 0.023) than did the CCS group. The incidence of osteonecrosis was higher in the CCS group, whereas the incidence of nonunion or malunion was higher in the FNS group. The surgical method did not appear to be a significant risk factor. The main risk factor for revision surgery was longer duration until the first adverse event (P = 0.015).

CONCLUSION

The FNS does not appear to provide superior surgical outcomes compared with CCSs in older adult women with Pauwels classification type II femoral neck fractures. A longer duration between surgical fixation and the first adverse event before stabilization of the fracture site may be a risk factor for revision surgery.

Controversies around hip fracture treatment: clinical evidence versus trends from national registries

PURPOSE

Several controversies in the optimal treatment of femoral neck fractures persist, together with large variations in clinical practice.

METHODS

A narrative literature review covering 4 current controversies in the surgical management of femoral neck fractures (total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented HA, internal fixation versus arthroplasty, operative versus non-operative) was performed. Available literature was balanced against annual trends in the management of femoral neck fractures from the public domain of several national registries (Sweden, Norway, The Netherlands, Australia and New Zealand).

RESULTS

For most controversies, the literature provides stronger evidence than is reflected by variations encountered in daily practice. Implementation of clinical evidence tends to lag behind and important differences exist between countries.

CONCLUSIONS

Trends of clinical practice from national registries indicate that implementation of available clinical evidence needs to be improved.

Management of Femoral Neck Fractures in Patients 50 Years or Older by American Board of Orthopaedic Surgery Part II Examination Candidates

OBJECTIVE

Assess associations between fellowship training, procedure, and performance in femoral neck fracture (FNF) surgery on adults by American Board of Orthopaedic Surgery Part II examination candidates.

SETTING

American Board of Orthopaedic Surgery SCRIBE database examination years 2007-2020.

PARTICIPANTS

Six thousand seven hundred seventy-seven candidates performing 39,283 FNF surgeries on adults 50 years or older.

INTERVENTION

Fellowship training.

MAIN OUTCOME MEASUREMENTS

Case volume; procedure performed: internal fixation, hemiarthroplasty, or total hip arthroplasty (THA); complications; readmission; reoperation.

RESULTS

Over the observation period, fewer candidates reported FNF surgery (68% overall, -0.6%/year, R 2 = 0.80) while more candidates reported fellowship training (87% overall, +1.4%/year, R 2 = 0.81). The rate of any complication was significantly associated with fellowship training (32% overall, P < 0.001). Readmission (12%, P = 0.080) and reoperation (5%, P = 0.531) were not significantly associated with fellowship training. The odds of any complication (odds ratio [OR] = -0.03 [95% CI, -0.07 to -0.001] per 10 cases) and surgical complication (OR = -0.12 [95% CI, -0.17 to -0.07] per 10 cases) were negatively associated with candidate FNF case volume. In total, 3,396 THA for FNF were performed (8% of cases). THA use increased 25 cases/year (R 2 = 0.83) and was associated with adult reconstruction ( P < 0.001) and oncology ( P < 0.001) fellowship training. Any complication of THA for FNF (32%, P = 0.261), readmission (9% overall, P = 0.321), and reoperation (5%, P = 0.200) was not significantly associated with fellowship training.

CONCLUSIONS

Between 2007 and 2020, femoral neck fracture surgery was performed by fewer American Board of Orthopaedic Surgery Part II examination candidates and there was greater use of THA. Over this period, the prevalence of fellowship training increased. Complications were not associated with fellowship training. Complications were associated with FNF case volume.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Residents´ Results Seem to be Non-Inferior Comparing to More Experienced Surgeons in Femoral Neck Fracture Osteosynthesis

Purpose of the Study

Femoral neck fracture osteosynthesis is usually performed by using dynamic hip screw (DHS) or multiple parallel cannulated screws (MCS). In orthopedic surgery training, certain hip fractures are one of the most common operations performed by residents. It has been questioned, whether residents can provide as safe treatment and patient outcomes as those of more experienced surgeons. The aim of this study was to evaluate the effect of surgical experience on risk of complications by comparing the surgical performance and clinical outcomes in femoral neck osteosyntheses between surgical residents and orthopaedic surgeons.

Methods

All patients with femoral neck fracture admitted to Helsinki and Uusimaa Hospital District (HUS) Hyvinkää Hospital from 2011 to 2016 were collected as research material. 88 hip fractures (87 patients) treated with DHS or MCS osteosyntheses were included in this study. The patients were divided into 2 groups, based on the surgeon's experience: an orthopedic surgeon group (n = 68) and a surgical resident group (n = 20). All data from complications, reoperations, and the duration of operations were collected.

Results

There was no significant difference in characteristics of operated patients between orthopaedics and residents group. There was no significant difference in complications or re-operations between groups (p = 0.4, p = 0.2). Surgical residents had statistically longer surgical time (mean 76 min, 95% CI 62.92 min, mean 46 min, 95% Cl 42.51 min; p-value < 0.001). Still surgical time was not a risk factor for complication (p-value 0.5).

Conclusion

Our results show that surgical residents´ outcomes in femoral neck fracture osteosynthesis seem to be as favorable as those of orthopedic surgeons; the operations just last slightly longer.

Hemiarthroplasty Versus Total Hip Arthroplasty for Femoral Neck Fracture in Elderly Patients: Twelve-Month Risk of Revision and Dislocation in an Instrumental Variable Analysis of Medicare Data

BACKGROUND

There is practice variation in the selection of a total hip arthroplasty (THA) or a hemiarthroplasty (HA) for the treatment of displaced femoral neck fractures in elderly patients. Large data sets are needed to compare the rates of rare complications following these procedures. We sought to examine the relationship between surgery type and secondary hip surgery (revision or conversion arthroplasty) at 12 months following the index arthroplasty, and that between surgery type and dislocation at 12 months, among elderly Medicare beneficiaries who underwent THA or HA for a femoral neck fracture, taking into account the potential for selection bias.

METHODS

We performed a population-based, retrospective study of elderly (>65 years of age) Medicare beneficiaries who underwent THA or HA following a femoral neck fracture. Two-stage, instrumental variable regression models were applied to nationally representative Medicare medical claims data from 2017 to 2019.

RESULTS

Of the 61,695 elderly patients who met the inclusion criteria, of whom 74.1% were female and 92.2% were non-Hispanic White, 10,268 patients (16.6%) underwent THA and 51,427 (83.4%) underwent HA. The findings from the multivariable, instrumental variable analyses indicated that treatment of displaced femoral neck fractures with THA was associated with a significantly higher risk of dislocation at 12 months compared with treatment with HA (2.9% for the THA group versus 1.9% for the HA group; p = 0.001). There was no significant difference in the likelihood of 12-month revision/conversion between THA and HA.

CONCLUSIONS

The use of THA to treat femoral neck fractures in elderly patients is associated with a significantly higher risk of 12-month dislocation, as compared with the use of HA, although the difference may not be clinically important. A low overall rate of dislocation was found in both groups. The risk of revision/conversion at 12 months did not differ between the groups.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Outcomes Following Hemiarthroplasty for Femoral Neck Fracture in Patients Who Have Hemiparesis

BACKGROUND

Hemiparesis increases the risk of femoral neck fracture (FNF) in the elderly, which frequently necessitates hemiarthroplasty. There are limited reports on the outcomes of hemiarthroplasty in patients who have hemiparesis. The purpose of this study was to evaluate hemiparesis as a potential risk factor for medical and surgical complications following hemiarthroplasty.

METHODS

Hemiparetic patients who have concomitant FNF and underwent hemiarthroplasty with at least 2 years of follow-up were identified using a national insurance database. A 10:1 matched control cohort of patients who did not have hemiparesis was created for comparison. There were 1,340 patients who have and 12,988 patients who did not have hemiparesis undergoing hemiarthroplasty for FNF. Multivariate logistic regression analyses were used to evaluate rates of medical and surgical complications between the 2 cohorts.

RESULTS

Aside from increased rates of medical complications including cerebrovascular accident (P < .001), urinary tract infection (P = .020), sepsis (P = .002), and myocardial infarction (P < .001), patients who have hemiparesis also experienced higher rates of dislocation within 1 and 2 years (Odds Ratio (OR) 1.54, P = .009; OR 1.52, P = .010). Hemiparesis was not associated with higher risk of wound complications, periprosthetic joint infection, aseptic loosening, and periprosthetic fracture, but was associated with higher incidence of 90-day ED-visits (OR 1.16, P = .031) and 90-day readmission (OR 1.32, P < .001).

CONCLUSION

While patients who have hemiparesis do not have increased risk of implant-related complications other than dislocation, they are at increased risk of developing medical complications following hemiarthroplasty for FNF.

Reduced mortality associated to cementless total hip arthroplasty in femoral neck fracture

Mortality related to femoral neck fractures remains a challenging health issue, with a high mortality rate at 1 year of follow-up. Three modifiable factors appear to be under control of the surgeon: the choice of the implant, the use of cement and the timing before surgery. The aim of this research project was to study the impact on mortality each of these risk factors play during the management of femoral neck fractures. A large retrospective epidemiological study was performed using a national database of the public healthcare system. The inclusion criteria were patients who underwent joint replacement surgery after femoral neck fracture during the years 2015 to 2017. All data points were available for at least 2 years after the fracture. The primary outcome was mortality within 2 years following the surgery. We evaluated the association between mortality and the type of the implant hemiarthroplasty (HA) versus total hip arthroplasty (THA), cemented versus non cemented femoral stem as well as the timing from fracture to surgical procedure. A multivariate analysis was performed including age, gender, comorbidities/autonomy scores, social category, and obesity. We identified 96,184 patients who matched the inclusion criteria between 2015 and 2017. 64,106 (66%) patients underwent HA and 32,078 (33.4%) underwent THA. After multivariate analysis including age and comorbidities, patients who underwent surgery after 72 h intra-hospital had a higher risk of mortality: Hazard Ratio (HR) = 1.119 (1.056-1.185) p = 0.0001 compared to the group who underwent surgery within 24 h. THA was found to be a protective factor HR = 0.762 (0.731-0.795) p < 0.0001. The use of cement was correlated with higher mortality rate: HR = 1.107 (1.067-1.149) p < 0.0001. Three key points are highlighted by our study in the reduction of mortality related to femoral neck fracture: the use of hemiarthroplasty a surgery performed after 48 h and the use of cement for femoral stem fixation adversely affect mortality risk.

Treatment of Femoral Neck Fractures in the Elderly: A Survey of the Korean Hip Society Surgeons

Purpose

This study examined the methods for treatment of femoral neck fracture (FNF) preferred by members of the Korean Hip Society (KHS) and identified factors that influence decisions regarding the surgical intervention of choice.

Materials and Methods

A total of 97 members of the KHS responded to the 16-question survey which included questions about the mean number of surgeries performed each month for treatment of femoral neck fractures, the cut-off age for deciding between internal fixation and arthroplasty, the implant used most often, usage of cement, and factors influencing each decision.

Results

The mean cut-off age used when deciding between internal fixation and arthroplasty was 64 years old. Hemiarthroplasty (HA) (70%) was the most preferred option for treatment of displaced FNFs in cases where arthroplasty was indicated (total hip arthroplasty [THA] 19% and dual mobility THA 11%). The main reasons for selection of arthroplasty over reduction with internal fixation were age and pre-fracture ambulatory status. Pre-trauma ambulatory status and/or sports activity were the main factors in selection of HA over THA. Cement was used by 33% of responders. Poor bone quality and a broad femoral canal were factors that influenced the usage of cement.

Conclusion

Management of FNFs in the elderly is a major health problem worldwide; thus, remaining alert to current trends in treatment is essential for surgeons. The mean cut-off age used in deciding between internal fixation and arthroplasty was 64 years old. HA is the preferred method for treatment of displaced FNFs for members of the KHS.

Robotic-assisted systems for the safe and reliable treatment of femoral neck fractures: retrospective cohort study

BACKGROUND

Robots are being used in a wide range of surgical procedures. However, in clinical practice, the efficacy of orthopedic robotic-assisted treatment of femoral neck fractures is still poorly reported, particularly in terms of screw placement accuracy, femoral neck fracture healing rates and postoperative functional recovery. Moreover, there is a lack of comparative analysis between robot-assisted surgery and traditional surgical approaches.

PURPOSE

The purpose of this study was to compare the clinical outcomes of patients with femoral neck fractures treated with TiRobot-assisted hollow screw fixation with those of patients with femoral neck fractures treated with traditional surgical approaches.

METHODS

This study included 112 patients with femoral neck fracture who were treated from March 2017 to October 2021 with percutaneous hollow screw internal fixation. These included 56 cases in the TiRobot-assisted surgery group and 56 cases in the standard surgery group. After at least 1 year of follow-up, the treatment outcomes of the two groups were compared, including the amount of intraoperative bleeding, the duration of intraoperative fluoroscopy, the number of guide pin positioning adjustments, the length of hospital stay, the accuracy rate of screw placement, the final Harris Hip Score, the fracture healing rate, and the rate of femoral head necrosis. Statistical analysis software was used to process and analyze the result.

RESULTS

The TiRobot-assisted group had a statistically significant improvement over the control group in terms of intraoperative bleeding, the duration of intraoperative fluoroscopy, the number of guide pin positioning adjustments, length of hospital stay, accuracy of screw placement and incidence of femoral head necrosis (P < 0.05). There was no statistically significant difference in time to surgery, final Harris hip score and fracture healing rate (P > 0.05).

CONCLUSION

This study shows that TiRobot-assisted surgery has the advantages of short hospital stay, high safety, minimally invasive, high success rate of nail placement, and can reduce the amount of intraoperative radiation and the incidence of femoral head necrosis, thus achieving satisfactory clinical outcomes, and is worthy of clinical promotion.

A three-dimensional measurement study of fracture displacement in Garden I femoral neck fracture: a retrospective study

BACKGROUND

Garden I femoral neck fractures are nondisplaced femoral neck fractures. Nonoperative treatment and in situ fixation are the preferred treatments. However, the postoperative outcome is not satisfactory and the incidence of complications remains high, which raises doubts about the accuracy of the diagnosis of nondisplaced Garden I fractures. Recently, three-dimensional (3D) reconstruction has been reported as a mature technology for reconstructing the bone structure of patients. We further extended this technique in the measurement of the fracture spatial displacement to verify the accuracy of Garden I femoral neck fractures.

METHODS

This was a retrospective study of patients with Garden I femoral neck fractures from January 2013 to December 2018 at our institution, who were included according to specified criteria. A bilateral proximal femur model of each patient was established based on computed tomography (CT) data. The displacement of the deepest portion of the femoral head fovea, the displacement of the center of the femoral head and the rotation of the femoral head were measured in the bilateral model.

RESULTS

A total of 102 patients diagnosed with Garden I fractures were included in this study. The cohort included 32 men and 70 women, with an average age of 55.88 ± 15.32 years. In these patients, the average displacement of the deepest portion of the femoral head fovea was 16.43 ± 7.69 mm. The minimum and maximum displacement was 3.58 and 44.32 mm, respectively. The average displacement of the center of the femoral head was 10.39 ± 5.47 mm and ranged from 2.16 to 34.42 mm. The rotational angle was 23.81 ± 10.15 ° and ranged from 3.71 ° to 61.19 °.

CONCLUSIONS

Garden I fractures have large spatial displacement and cannot be considered incomplete or nondisplaced fractures. Therefore, we suggest that anatomical reduction should be considered during treatment.

Revision risk of salvage compared with acute total hip arthroplasty following femoral neck fracture: an analysis from the Dutch Arthroplasty Register

BACKGROUND AND PURPOSE

There is no consensus on the treatment of patients with femoral neck fractures between internal fixation (IF) or directly treated with a total hip arthroplasty (fracture-THA) in particular for the age group 60-70 years. Failure of IF is not uncommon, resulting in salvage total hip arthroplasty (salvage-THA). The aim of our study was to compare revision rates of salvage-THA with fracture-THA and osteoarthritis (OA)-THA.

PATIENTS AND METHODS

Revision rates and reasons for revision were compared. Data collected in the Dutch Arthroplasty Register (LROI) between 2007 and 2018 was used. The study included 4,310 salvage-THAs, 12,159 fracture-THAs, and 274,147 OA-THAs. We performed Kaplan-Meier survival analyses and Cox regression to evaluate THA survival.

RESULTS

No statistically significant difference in revision rates between salvage-THAs and fracture-THAs was found (HR 1.0, 95% CI 0.7-1.3) whereas the revision rate was higher compared with OA-THAs (HR 1.3, CI 1.0-1.5). The 5-year revision rate was 5.0% (CI 4.4-5.8) in salvage-THAs, 4.5% (CI 4.1-5.0) in fracture-THAs, and 3.1% (CI 3.0-3.2) in OA-THAs. A higher revision rate for infection was found in salvage-THAs in comparison with fracture-THAs (HR 1.6, CI 1.0-2.3).

CONCLUSION

We found no difference in revision rates for salvage-THAs compared with fracture-THAs. The risk of revision for infection was higher for salvage-THA.

Incidence and Risk Factors of Short Axial Length of the Proximal Femur: A Caution in the Use of Femoral Neck System in Patients with Garden Type I/II Femoral Neck Fractures

BACKGROUND

In 2018, Femoral Neck System (FNS), a dedicated fixator for femoral neck fractures, was introduced. This device has been in increasing use because it provides excellent rotational and angular stability. However, the shortest bolt of FNS is 75 mm long. Thus, it is not usable when the axial length of the proximal femur (ALPF), the distance between the innominate tubercle and the surface of the femoral head, is less than 80 mm. In this study, we investigated the incidence and associated factors of small ALPF (< 80 mm) in femoral neck fracture patients.

METHODS

We measured the ALPF on preoperative computed tomography (CT) scans of 261 patients (166 women and 55 men), who were operated due to nondisplaced or impacted femoral neck fractures. The ALPF was measured on reconstructed oblique coronal images along the femoral neck. We evaluated the distribution of ALPF, calculated the incidence of small ALPF (< 80 mm), and correlated it with patient's height, weight, body mass index, age, bone mineral density (T-score), and caput-column-diaphysis angle.

RESULTS

The ALPF ranged from 67.4 mm to 107.1 mm (mean, 88.4 mm; standard deviation, 7.2 mm). In 19 patients (8.6%, 19 / 221), the length was < 80 mm. The ALPF was strongly correlated with height (correlation coefficient = 0.707, R2 = 0.500, p < 0.001) and moderately correlated with weight (correlation coefficient = 0.551, R2 = 0.304, p < 0.001). The T-score was moderately correlated with the ALPF (correlation coefficient = 0.433, R2 = 0.187, p < 0.001). The age was moderately correlated with the ALPF (correlation coefficient =-0.353, R2 = 0.123, p < 0.001).

CONCLUSIONS

A considerable percentage of femoral neck fracture patients (8.6%) had small proximal femurs (ALPF < 80 mm), which cannot be operated with FNS. We recommend measuring the ALPF using reconstructed oblique coronal CT images or scaled hip radiographs: en face view of the femoral neck prior to surgery in patients with short stature and/or low body weight. If the ALPF is < 80 mm, the surgeon should prepare other fixation devices.

What makes vertical femoral neck fracture with posterior inferior comminution different? An analysis of biomechanical features and optimal internal fixation strategy

BACKGROUND AND PURPOSE

Fracture comminution occurs in 83.9%-94% of vertical femoral neck fractures (VFNFs), the majority of which were located in posterior-inferior region, and poses a clinical challenge in fixation stability. We conducted a subject-specific finite element analysis to determine the biomechanical features and optimal fixation selection for treating VFNF with posterior-inferior comminution.

PATIENTS AND METHODS

Eighteen models with three fracture types (VFNF without comminution [NCOM], with comminution [COM], with comminution + osteoporosis [COMOP]) and six internal fixation types (alpha [G-ALP], buttress [G-BUT], rhomboid [G-RHO], dynamic hip screw [G-DHS], invert triangle [G-ITR], femoral neck system (G-FNS)) were created based on the computed tomography data. By using the subject-specific finite element analysis method, stiffness, implant stress, yielding rate (YR) were compared. Additionally, in order to elucidate distinct biomechanical characters of different fracture types and fixation strategies, we calculated interfragmentary movement (IFM), detached interfragmentary movement (DIM), shear interfragmentary movement (SIM) of all fracture surface nodes.

RESULTS

Generally, in comparison with NCOM, COM showed a 30.6% reduction of stiffness and 1.46-times higher mean interfragmentary movement. Besides, COM had a 4.66-times (p = 0.002) higher DIM at the superior-middle position, but similar SIM across fracture line, which presented as varus deformation. In COM and COMOP, among all six fixation strategies, G-ALP had significantly the lowest IFM (p<0.001) and SIM (p<0.001). Although G-FNS had significantly highest IFM and SIM (p<0.001), it had the highest stiffness and lowest DIM (p<0.001). In COMOP, YR was the lowest in G-FNS (2.67%).

CONCLUSIONS

Posterior-inferior comminution primarily increases superior-middle detached interfragmentary movement in VFNF, which results in varus deformation. For comminuted VFNF with or without osteoporosis, alpha fixation has the best interfragmentary stability and anti-shear property among six current mainstream fixation strategies, but a relatively weaker stiffness and anti-varus property compared to fixed-angle devices. FNS is advantageous owing to stiffness, anti-varus property and bone yielding rate in osteoporosis cases, but is insufficient in anti-shear property.

Infection after intracapsular femoral neck fracture - does antibiotic-loaded bone cement reduce infection risk after hemiarthroplasty and total hip arthroplasty?

Aims

The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture.

Methods

Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching.

Results

Overall in 13,612 cases of intracapsular femoral neck fracture, 9,110 (66.9%) HAs and 4,502 (33.1%) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared with uncemented fixated prosthesis (p = 0.013). In patients with THA no statistical difference between cemented and uncemented prosthesis was registered, however after one year 2.4% of infections were detected in uncemented and 2.1% in cemented THA. In the subpopulation of HA after one year, 1.9% of infections were registered in cemented and 2.8% in uncemented HA. BMI (p = 0.001) and Elixhauser Comorbidity Index (p < 0.003) were identified as risk factors of periprosthetic joint infection (PJI), while in THA cemented prosthesis also demonstrated an increased risk within the first 30 days (hazard ratio (HR) = 2.73; p = 0.010).

Conclusion

The rate of infection after intracapsular femoral neck fracture was statistically significantly reduced in patients treated by antibiotic-loaded cemented HA. Particularly for patients with multiple risk factors for the development of a PJI, the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection.

Internal Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare internal fixation (IF) versus hemiarthroplasty (HA) for elderly individuals (ie, older than 65 years) with nondisplaced (ie, Garden type I or II) femoral neck fracture (FNF).

DATA SOURCE

We searched English literature of MEDLINE, PubMed, and Embase from inception to December 4, 2021.

STUDY SELECTION

Eligibility criteria were randomized controlled trials (RCTs) compared IF versus HA for elderly individuals with nondisplaced FNF. Primary outcomes were Harris hip score (HHS), quality of life per European Quality of Life 5 Dimension (EQ-5D), and mortality. Secondary outcomes were complications, reoperation, intraoperative bleeding, operation duration, and length of hospital stay.

DATA EXTRACTION

Two authors separately extracted data and assessed the risk of bias of the included studies using Cochrane risk-of-bias tool.

DATA SYNTHESIS

Three RCTs yielding 400 patients were enrolled, of which 203 (50.7%) underwent IF. Internal fixation was inferior to HA with respect to 6-month HHS [mean difference (MD) = -8.28 (-14.46, -2.10), P = 0.009] and 1-year EQ-5D [MD = -0.07 (-0.14, -0.00), P = 0.04]. The 2 techniques were comparable regarding length of hospital stay (day), HHS at 1 and 2 years, EQ-5D at 2 years, and mortality. IF was inferior to HA in implant-related complication [20.1% vs. 6.0%, relative risk (RR) = 3.18 (1.72, 5.88), P = 0.0002] and reoperation rate [20.1% vs. 6.0%, RR = 3.30 (1.79, 6.08), P = 0.0001]. Hemiarthroplasty had a greater blood loss (mL) [MD = -138.88 (-209.58, -68.18), P = 0.001] and operation duration (min) [MD = -23.27 (-44.95, -1.60), P = 0.04] compared with IF.

CONCLUSION

HA is the preferred technique for nondisplaced FNF if early recovery, higher mobility, and better quality of life are priorities. The choice of fixation should be weighed on an individual patient level.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty for displaced femoral neck fracture: Survey of orthopaedic surgeons in Ontario, Canada

BACKGROUND

Total hip arthroplasty (THA) for displaced femoral neck fractures in older patients remains a controversial topic. This study describes patient and surgeon factors that are associated with surgeons' recommendation of THA for this patient population. Furthermore, this study explores surgeon perceptions on why most patients are treated with hemiarthroplasty over THA.

METHODS

In October 2019, a cross-sectional survey was mailed to practicing orthopaedic surgeons in Ontario, Canada. The questionnaire included paper patient cases to capture surgical practice variation using a full factorial, vignette-based experimental design. Multilevel linear regression and multivariable linear regression were used to determine patient and surgeon factors that are associated with treatment recommendations.

RESULTS

Of a target population of 494 practicing surgeons, 302 (61.1%) responded. Sixty percent of respondents worked in the community, and most respondents (89.4%) had fellowship training. Surgeon-level predictors of treatment with THA included higher volume of THA for fracture in the last 12 months, having an elective THA practice, and increasing years in practice. Pre-existing hip arthritis increased likelihood to recommend THA, while increasing patient age and comorbidity burden decreased likelihood to recommend THA. There are medical, institutional, financial, and historic reasons why most patients are treated with hemiarthroplasty over THA.

INTERPRETATION

This survey identified several patient and surgeon-level factors that were associated with treatment recommendation for THA. Hemiarthroplasty remains the more common treatment for this patient population for multiple reasons. There is potential for differential access to care when the factors driving treatment decisions are unrelated to the patient.

The Prophylactic Effect of Single vs. Dual Antibiotic-Loaded Bone Cement against Periprosthetic Joint Infection Following Hip Arthroplasty for Femoral Neck Fracture: An Analysis of the German Arthroplasty Registry

BACKGROUND

Antibiotic-loaded bone cement in arthroplasties is currently experiencing increased usage. Therefore, single and double antibiotic-loaded bone cements are commercially available and used in orthopedic surgery. The aim of this investigation was to compare the clinical use of single compared to dual antibiotic-loaded bone cement for implant fixation after femoral neck fracture. Further infection rates were to be compared in (partial) arthroplasty for the treatment of femoral neck fracture for both treatment options.

METHODS

On the basis of the German Arthroplasty Registry (EPRD), all cases of femoral neck fracture treated with hemiarthroplasty (HA), or total hip arthroplasty (THA) with single and dual antibiotic-loaded bone cement, were included into the data analysis. The infection risk was compared using Kaplan-Meier estimates.

RESULTS

In total, 26,845 cases (HA 76.3%-THA: 23.7%) with femoral neck fracture were included. Within recent years, an increasing usage of dual antibiotic-loaded cement in Germany, with a current proportion of 7.30% in arthroplasty procedures for femoral neck fracture treatment, has been observed. In patients treated with HA, the proportion of dual antibiotic-loaded cement was 7.86%, while in those treated with THA, 5.46% of all prostheses were fixated with a two antibiotic component cement. For all arthroplasty procedures using single antibiotic-loaded bone cement after six months 1.8%, after one year 1.9%, and after five years 2.3%, of the cases failed due to periprosthetic joint infection (PJI), while in the same time period, in cases with dual antibiotic-loaded bone cement 1.5%, 1.5% and 1.5% suffered from infection (p = 0.34). A infection rate of 1.1% after HA with dual antibiotic-loaded bone cement was reported, compared to a 2.1% infection rate whilst using single antibiotic-loaded bone cement after five years (p = 0.098). The number required for treatment when using HA was 91.

CONCLUSIONS

The use of dual antibiotic-loaded bone cement is increasingly used in arthroplasty procedures after femoral neck fractures. It demonstrates a reduction of PJI after HA and seems, therefore, to be a useful method for the prevention of infection, especially in patients with increased risk factors for PJI.

Cemented vs Uncemented hemiarthroplasties for femoral neck fractures: An overlapping systematic review and evidence appraisal

BACKGROUND

The purpose of our study is to assess the methodology of overlapping systematic reviews related to cemented vs uncemented hip hemiarthroplasties for the treatment of femoral neck fractures to find the study with the best evidence. Also, we assess the gaps in methodology and information to help with direction of future studies.

METHODS

A systematic search was conducted in September 2022 using Pubmed, Embase, and Cochrane Library. Clinical outcome data and characteristics of each study were extracted to see which treatment had better favorability. The outcomes and characteristics extracted from each study includes, first author, search date, publication journal and date, number of studies included, databases, level of evidence, software used, subgroup analyses that were conducted, and heterogeneity with the use of I2 statistics Methodological quality information was extracted from each study using four different methodologic scores (Oxford Levels of Evidence; Assessment of Multiple Systematic Reviews (AMSTAR); Quality of reporting of meta-analyses (QUROM); Oxman and Guyatt. After that, the Jadad decision algorithm was used to identify which studies in our sample contained the best available evidence. Finally, overlap of each systematic review was assessed using Corrected Covered Area (CCA) to look at redundancy and research waste among the systematic reviews published on the topic.

RESULTS

After screening, 12 studies were included in our sample. For the Oxford Levels of Evidence, we found that all the studies were Level I evidence. For the QUORUM assessment, we had 1 study with the highest score of 18. Additionally, we did the Oxman and Guyatt assessment, where we found 4 studies with a maximum score of 6. Finally, we did an AMSTAR assessment and found 2 studies with a score of 9. After conducting the methodological scores; the authors determined that Li. L et al 2021 had the highest quality. In addition, it was found that the CCA found among the primary studies in each systematic review calculated to .22. Any CCA above .15 is considered "very high overlap".

CONCLUSIONS

The best available evidence suggests that Cemented HAs are better at preventing Prosthesis-related complications. Conversely, the best evidence also suggests that Cemented HA also results in longer operative time and increased intraoperative blood loss. When conducting future systematic reviews related to the topic, we ask that authors restrict conducting another systematic review until new evidence emerges so as not to confuse the clinical decision-making of physicians.

A systematic review and meta-analysis of cemented and uncemented bipolar hemiarthroplasty for the treatment of femoral neck fractures in elderly patients over 60 years old

Background

Currently, whether bone cement can be applied in bipolar hemiarthroplasty to treat femoral neck fractures (FNFs) in elderly patients is controversial. The aim of this systematic review and meta-analysis was to compare the effectiveness and safety of cemented bipolar hemiarthroplasty (CBH) versus uncemented bipolar hemiarthroplasty (UCBH) in the treatment of FNFs among elderly patients over 60 years old.

Materials and methods

The Pubmed, Web of science, Cochrane Library and EMBASE databases were searched comprehensively for relevant articles from their inception to May 2022. Studies about comparing outcomes between CBH and UCBH for FNFs in elderly patients aged more than 60 years were included. Outcomes including operation time, intra-operative blood loss, length of hospital stay, wound infections, residual pain, revisions, re-operations, complications related to prosthesis, general complications, and mortality. The Review Manager 5.3 software provided by the Cochrane Collaboration Network was used to perform the meta-analysis of comparable data.

Results

A total of 6 randomized controlled trials (RCTs) and 9 observational studies were included in this analysis, with 33,118 patients (33,127 hips). Results of the meta-analysis indicated that the operation time [WMD = 13.01 min, 95% CI (10.79, 15.23)], intra-operative blood loss [WMD = 80.57 ml, 95% CI (61.14, 99.99)], incidence of heterotrophic ossification [OR = 2.07, 95% CI (1,14, 3.78)], were increased in the CBH group but the incidence of intra-operative fractures [OR = 0.24, 95% CI (0.07, 0.86)], periprosthetic fractures [OR = 0.24, 95% CI (0.18, 0.31)], aseptic loosening of prosthesis [OR = 0.20, 95% CI (0.09, 0.44)], wound infections [OR = 0.80, 95% CI (0.68, 0.95)] and re-operation rates [OR = 0.61, 95% CI (0.54, 0.68)] were lower in the CBH group by comparison with the UCHB group. However, there were no significant differences in residual pain, length of hospital stay, prosthetic dislocation, prosthetic subsidence (> 5 mm), acetabulum erosion, revisions, pulmonary infections, pulmonary embolisms, urinary tract infections, deep venous thromboses, decubitus, cardiovascular accidents (arrhythmia/myocardial infarction), and respiratory failure between the two groups. In terms of mortality, perioperative mortality (within 72 h) [OR = 2.39, 95% CI (1.71, 3.32)] and 1-week mortality postoperatively [OR = 1.22, 95% CI (1.05, 1.41)] in CBH group were higher than those in UCBH group, but there were no significant differences in mortality at 1 month, 3 months, 1 year, and 2 years postoperatively between CBH group and UCBH group.

Conclusion

This meta-analysis found that elderly patients over 60 years old with FNFs who underwent CBH had longer operation time, higher incidence of heterotrophic ossification, intra-operative blood loss, and mortality within 72 h of operation and at 1-week postoperatively, but lower incidence of periprosthetic fractures, aseptic loosening of prosthesis, intra-operative fractures, wound infections and re-operations. Other outcomes were not significantly different between the two groups.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021274253.

Biomechanical study of femoral neck system for young patients with nonanatomically reduced femoral neck fractures: a finite element

BACKGROUND

A consensus regarding the optimal approach for treating femoral neck fractures is lacking. We aimed to investigate the biomechanical outcomes of Femoral Neck System (FNS) internal fixation components in the treatment of nonanatomically reduced femoral neck fractures.

METHOD

We constructed two types of femoral neck fractures of the Pauwels classification with angles of 30° and 50°, and three models of anatomic reduction, positive buttress reduction and negative buttress reduction were constructed. Subgroups of 1 to 4 mm were divided according to the distance of displacement in the positive buttress reduction and negative buttress reduction models. The von Mises stress and displacements of the femur and FNS internal fixation components were measured for each fracture group under 2100-N axial loads.

RESULTS

When the Pauwels angle was 30°, the positive 1-mm and 2-mm models had lower FNS stress than the negative buttress model. The positive 3- and 4-mm models showed FNS stress similar to that of the negative buttress model. But the four positive buttress models had similar stresses on the femur as the negative buttress model. When the Pauwels angle was 50°, the four positive buttress models had higher FNS stress than the negative buttress model. Three positive buttress models (2 mm, 3 and 4 mm) resulted in lower stress of the femur than the negative buttress model, though the 1-mm model did not. When the Pauwels angle was 30°, the positive buttress model had a lower displacement of the FNS than the negative buttress model and a similar displacement of the femur with the negative buttress model. When the Pauwels angle was 50°, the positive buttress model had a higher displacement of the FNS and femur than the negative buttress model. Our study also showed that the von Mises stress and displacement of the internal fixation and the femur increased as the fracture angle increased.

CONCLUSION

From the perspective of biomechanics, when the Pauwels angle was 30°, positive buttress was more stable to negative buttress. However, when the Pauwels angle was 50°, this advantage weakens. In our opinion, the clinical efficacy of FNS internal fixation with positive buttress may be related to the fracture angle, neck-shaft angle and alignment in the lateral view. This result needs verification in further clinical studies.

Mobility and Hip Function Among Geriatric Patients With Displaced Neck of Femur Fractures Treated With Arthroplasty

Background

Neck of femur fractures result in impaired function for older people. Despite surgery, many patients experience a decrease in functional level and poorer health status after the injury. The objectives of this study were (1) to determine the short-term mobility and hip function of geriatric patients who underwent hip replacement surgery for a displaced neck of femur fracture in our local population and (2) to identify factors which affect the functional outcome of these patients.

Methods

Patients aged 60 years and above, who were admitted for neck of femur fracture from January 2017 to December 2020, and treated surgically with arthroplasty, were included. Information on patient demography, comorbidities, perioperative data, mobility, hip function and complications were retrospectively collected. Outcome measures used were independent ambulation and recovery of pre-fracture mobility at 1 year after surgery while hip function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total, pain, stiffness, and physical function scores. Factors associated with these outcomes were analyzed.

Results

168 patients with a mean age of 75.2 (SD 8.4) years met the inclusion criteria. 32.1% of patients regained their pre-fracture mobility and 59.6% remained independent 1 year after surgery. Logistic regression analysis identified age, gender, surgical procedure, and time to surgery as significant contributors to recovery of pre-fracture mobility. Older age and increasing requirement for postoperative ambulatory aid resulted in worse WOMAC total and physical function scores. No significant differences were observed in patient-reported hip function between those who had a total hip arthroplasty and those who had a hemiarthroplasty.

Conclusion

Most geriatric patients with displaced neck of femur fractures did not regain pre-fracture mobility despite surgical treatment with arthroplasty.

Dual-mobility cup total hip arthroplasty improves the quality of life compared to internal fixation in femoral neck fractures patients with severe neuromuscular disease in the lower extremity after stroke: a retrospective study

Background

This study aimed to demonstrate that dual-mobility cup total hip arthroplasty (DMC-THA) can significantly improve the quality of life (QOL) of elderly femoral neck fracture patients with severe neuromuscular disease in unilateral lower extremities due to stroke hemiplegia compared to internal fixation (IF).

Methods

Fifty-eight cases of severe neuromuscular disease in the unilateral lower extremities with muscle strength < grade 3/5 due to stroke were retrospectively examined From January 2015 to December 2020. Then, patients were divided into DMC and IF groups. The QOL was examined using the EQ-5D and SF-36 outcome measures. The physical and mental statuses were assessed using the Barthel Index (BI) and e Fall Efficacy Scale-International (FES-I), respectively.

Results

Patients in the DMC group had higher BI scores than those in the IF group at different time point. Regarding mental status, the FES-I mean score was 42.1 ± 5.3 in the DMC group and 47.3 ± 5.6 in the IF group (p = 0.002). For the QOL, the mean SF-36 score was 46.1 ± 18.3 for the health component and 59.5 ± 15.0 for the mental component in the DMC group compared to 35.3 ± 16.2 (p = 0.035), and 46.6 ± 17.4 (p = 0.006) compared to the IF group. The mean EQ-5D-5L values were 0.733 ± 0.190 and 0.303 ± 0.227 in the DMC and IF groups (p = 0.035), respectively.

Conclusion

DMC-THA significantly improved postoperative QOL compared to IF in elderly patients with femoral neck fractures and severe neuromuscular dysfunction in the lower extremity after stroke. The improved outcomes were related to the enhanced early, rudimentary motor function of patients.